A summary of the "must-read" articles from the journals in that pile on your desk.
Dilated Cardiomyopathy More Common in Boys
Children have outcomes similar to adults
In patients under age 18, dilated cardiomyopathy is more common in boys than girls and in blacks than whites, and their outcomes are similar to those seen in adults, according to a study in the Oct. 18 issue of the Journal of the American Medical Association.
Jeffrey A. Towbin, M.D., of the Baylor College of Medicine and Texas Children's Hospital in Houston, and colleagues conducted a longitudinal study of 1,426 U.S. and Canadian children with dilated cardiomyopathy.
The researchers found that the annual incidence of dilated cardiomyopathy in children younger than 18 years was 0.57 cases per 100,000 and that it was higher in boys than in girls (0.66 vs. 0.47 cases), in blacks than in whites (0.98 vs. 0.46 cases) and in infants than in children (4.40 vs. 0.34 cases). In most cases, they found that the cause was unknown. Of known causes, the most common ones were identified as myocarditis (46 percent) and neuromuscular disease (26 percent). They also found that the one- and five-year rates of death or transplantation were 31 percent and 46 percent, respectively, which are comparable to rates seen in adults.
"New methods for early diagnosis and risk stratification, as well as new therapies, need to be developed for infants and children with dilated cardiomyopathy to avoid transplantation and premature death," the authors write.
Trigeminal Neuralgia Case Linked to Tongue Piercing
Atypical trigeminal neuralgia quickly resolves after removal of piercing
An 18-year-old woman who presented with a two-month history of neuropathic facial pain that she described as "electrical shocks" was found to have atypical trigeminal neuralgia due to a recent tongue piercing, according to a research letter published in the Oct. 18 issue of the Journal of the American Medical Association.
In the letter, Marcelo Galarza, M.D., of Villa Maria Cecilia Hospital in Ravenna, Italy, and colleagues describe the patient, who had pain that began one month after a piercing with a bispherical metal stud, or barbell. The pain occurred for 30 seconds up to 30 times per day.
Carbamazepine temporarily reduced the frequency of pain but was no longer effective after one week of treatment, despite therapeutic levels of the drug. The pain resolved 48 hours after removal of the piercing and the patient remains pain-free after one year.
"The syndrome was probably secondary to a lingual metallic implant, and although findings indicate involvement of the trigeminal system, the location of the piercing and implant should not have resulted in trigeminal injury," the authors write. "To our knowledge, this is the first published report of atypical trigeminal neuralgia associated with tongue piercing. This should be considered in the differential diagnosis of such symptoms."
Adverse Drug Events Lead to Emergency Department Visits
They may account for more than 700,000 visits each year; elderly disproportionately affected
Adverse drug events, or ADEs, may account for more than 700,000 emergency department visits in the United States each year, and the elderly are at higher risk of visits and hospitalizations than younger patients, researchers report in the Oct. 18 issue of the Journal of the American Medical Association.
Daniel S. Budnitz, M.D., M.P.H., of the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues analyzed 2004-2005 data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project (NEISS-CADES) and identified 21,298 ADEs.
Based on this data, the researchers estimated that ADEs accounted for 701,547 emergency department visits annually in 2004 and 2005. They also found that patients aged 65 and older were more than twice as likely to receive treatment for ADEs and almost seven times as likely to require subsequent hospitalization compared to younger patients. They identified 18 drugs associated with most ADEs and found that insulins or warfarins accounted for one in seven ADEs treated in emergency departments.
"Efforts to reduce the burden of outpatient ADEs have been hampered by sparse data, except in selected health care systems or settings," the authors write. "Ongoing data collection in NEISS-CADES will enable more detailed examination of the epidemiology of emergency department-treated outpatient ADEs, focusing on specific patient populations, drug classes, conditions and circumstances."
Breathing Exercises Reduce Pneumonia Risk After Bypass
Preoperative exercises reduce risk of pulmonary complications in high-risk patients
Patients who are at high risk of pneumonia or other pulmonary complications after coronary artery bypass graft surgery are less likely to experience problems if they undergo preoperative inspiratory muscle training (IMT), according to study results published in the Oct. 18 issue of the Journal of the American Medical Association.
Erik H.J. Hulzebos, P.T., M.Sc., of the University Medical Center Utrecht in the Netherlands, and colleagues randomly assigned 279 high-risk patients to receive either preoperative IMT or usual care. The IMT group trained daily for at least two weeks prior to surgery, focusing on forced expiration, incentive spirometry and active breathing techniques.
The researchers found that postoperative pulmonary complications were significantly lower in the IMT group compared to the usual care group (18 percent versus 35 percent). They also found a significantly lower incidence of pneumonia (6.5 percent versus 16.1 percent) and a shorter median postoperative hospital stay (7 days versus 8 days).
"To our knowledge, this is the first randomized clinical trial of a preoperative prophylactic tailored physical therapy intervention in patients scheduled for primary elective coronary artery bypass graft surgery, based on artery occlusion, who are at high risk of developing postoperative pulmonary complications," the authors state. "We consider this to be an important presurgical intervention that appears to be effective at reducing morbidity."
Fish Intake is Healthy Despite Risk of Contaminants
Eating one or two servings weekly may reduce cardiac death risk 36 percent
The health benefits of seafood consumption outweigh the risk of contaminants contained in some fish, but young women and nursing mothers should limit themselves to two weekly servings of certain species only, researchers report in the Oct. 18 issue of the Journal of the American Medical Association (JAMA). A separate report from the Institute of Medicine was also released Tuesday in an effort to help consumers sort through information on the risks and benefits of seafood consumption.
In the JAMA study, Dariush Mozaffarian, M.D., of Brigham and Women's Hospital in Boston, and a colleague analyzed studies assessing health problems and polychlorinated biphenyls and dioxins in fish; fish and fish oil consumption and methylmercury, neurological and cardiovascular health.
The researchers found that eating one or two weekly fish servings, especially fish containing more omega-3 fatty acids -- eicosapentaenoic acid and docosahexaenoic acid -- cut overall death risk 17 percent and coronary mortality risk 36 percent, and caused other health improvements.
"For major health outcomes among adults, based on both the strength of the evidence and the potential magnitudes of effect, the benefits of fish intake exceed the potential risks," the authors write. "For women of childbearing age, benefits of modest fish intake, excepting a few selected species, also outweigh risks."
Pregnant or breast-feeding women should avoid eating predatory fish with long life spans, such as swordfish, shark and tilefish, according to the Institute of Medicine report, which was funded by the National Oceanic and Atmospheric Administration and the U.S. Food and Drug Administration.
"Consumers need better guidance on making seafood choices," said Malden C. Nesheim, of Cornell University in Ithaca, N.Y., and chair of the committee that wrote the report, in a statement.
Donor's Hepatitis C Affects Heart-Transplant Outcome
Poor survival rates prompt recommendation against transplantation of HCV-positive hearts
Short- and long-term survival is significantly lower among heart-transplant patients who receive hearts from donors who were positive for the hepatitis C virus (HCV) than among patients who receive hearts from virus-free donors, according to a report published in the Oct. 18 issue of the Journal of the American Medical Association.
Leanne B. Gasink, M.D., of the University of Pennsylvania School of Medicine in Philadelphia, and colleagues studied outcomes in 10,915 patients who received transplants between April 1994 and July 2003. Of these, 261 received an HCV-positive donor heart.
The researchers found that survival rates were poorer in the HCV-positive donor-heart group compared to the HCV-negative donor-heart group at one year (83 percent versus 92 percent), five years (53 percent versus 77 percent) and 10 years (25 percent versus 53 percent).
The results "provide support for the position that transplanting hearts from HCV-positive donors should be avoided if possible. Studies in other organ recipients suggest similar results," state the authors of an accompanying editorial. "Exceptions could be made for critically ill patients who will not survive without a transplant."
Psychopathology Seen in Kids with Intellectual Disability
Over 40 percent have psychopathology, psychiatric disorder, but few get mental health care
About 41 percent of children and adolescents with intellectual disability also have major psychopathology, and while this decreases over time, only one in 10 receives mental health treatment, according to a study in the Oct. 25 issue of the Journal of the American Medical Association.
Stewart L. Einfeld, M.D., of the University of Sydney in Australia, and colleagues examined psychopathology in 578 children and adolescents with intellectual disability over 14 years, with data collected at four time waves. The researchers obtained data from 507 participants, with 84 percent of these followed up through the fourth time wave in 2002-2003.
Forty-one percent of subjects had major psychopathology or definite psychiatric disorder at baseline, which decreased to 31 percent by the end of the study. Psychopathology decreased more in boys than girls over time, and more in subjects with mild intellectual ability than in those with more severe intellectual impairment. Only 10 percent of participants with psychopathology received mental health treatment, the report indicates.
"These results provide evidence that the problem of psychopathology co-morbid with intellectual disability is both substantial and persistent and suggest the need for effective mental health interventions," Einfeld and colleagues conclude.
Einfeld and another colleague hold the copyright for the Developmental Behaviour Checklist, a measuring tool used in the research.
Minorities Seen Less Often at High-Volume Hospitals
Medicaid recipients, uninsured also less likely to get treatment
Non-whites, Medicaid recipients and the uninsured are less likely to receive treatment at high-volume hospitals in California, which are associated with better outcomes, according to a report in the Oct. 25 issue of the Journal of the American Medical Association.
Clifford Y. Ko, M.D., of the David Geffen School of Medicine at the University of California at Los Angeles, and colleagues compared the characteristics of 719,608 patients treated in low- and high-volume hospitals in California for one of 10 surgical procedures that included coronary angioplasty, pancreatic cancer resection and total knee replacement.
Compared with whites, blacks treated at high-volume hospitals were significantly less likely to be treated for six of the operations, Asians were less likely for five of the procedures and Hispanics were less likely for nine. Medicaid patients were less likely than Medicare patients to be treated at high-volume hospitals for seven of the operations, and the uninsured were less likely than the insured to receive care for nine of them.
"Providing quality equitably in a setting of diverse values and preferences, racial and social barriers, and differences in ability to pay is a particularly challenging task," writes the author of an accompanying editorial, who adds that the only true solution is to "eradicate the racial discrimination and economic injustice of the society in which the U.S. health care system functions."
Flu Vaccine Found to Be Safe in Youngest Children
No serious adverse events in children aged 6 months to 23 months
The trivalent inactivated flu vaccine is safe for children aged 6 months to 23 months, with no serious adverse events, according to a large trial reported in the Oct. 25 issue of the Journal of the American Medical Association.
Simon J. Hambidge, M.D., Ph.D., of Kaiser Permanente Colorado in Denver, and colleagues examined the safety of the trivalent inactivated influenza vaccine in 45,356 children between 6 months and 23 months of age who received the vaccine between 1991 and 2003.
The researchers found there were no conditions that were significantly more likely to occur after vaccination. Thirteen illnesses were less likely to occur after vaccination, including upper respiratory tract infection and otitis media.
"In the largest population-based study to date of the safety of trivalent inactivated influenza vaccine in young children, there were very few medically attended events, none of which were serious, significantly associated with the vaccine," Hambidge and colleagues conclude.
Several authors report having received funding from, or been employed by, drug companies.
Racial Disparities Seen in Medicare Managed Care Plans
Black Medicare enrollees perform lower than whites on select outcome measures
Quality of care is worse for black Medicare managed-care enrollees than their white counterparts, largely due to different outcomes in the same plan, not plan selection, according to a new analysis in the Oct. 25 issue of the Journal of the American Medical Association.
Amal N. Trivedi, M.D., M.P.H., of Brown University in Providence, R.I., and colleagues assessed the relationship between quality of care and racial disparities among Medicare managed-care enrollees using four Health Plan Employer and Data Information Set (HEDIS) measures: Glucose and low-density lipoprotein cholesterol (LDL-C) control among diabetics, blood pressure control among hypertensives and LDL-C control among patients who had had a coronary event.
Black Medicare enrollees performed 6.8 percent lower for blood pressure control and 14.4 percent lower for LDL-C, when compared to white enrollees. For each of the four measures used in the new study, more than 70 percent of the disparity was due to different outcomes for black and white enrollees in the same health plan, rather than selection of lower-performing plans by black enrollees.
"In Medicare health plans, disparities vary widely and are only weakly correlated with the overall quality of care. Therefore, plan-specific performance reports of racial disparities on outcome measures would provide useful information not currently conveyed by standard HEDIS reports," the authors conclude.
New Drug Promising for Immune Thrombocytopenia
Few adverse side effects seen in phase 1-2 trial of the new thrombopoietic agent, AMG 531
The thrombopoiesis-stimulating agent, AMG 531, appears to be safe and effective for boosting platelet counts in patients with immune thrombocytopenic purpura, according to a preliminary study in the Oct. 19 issue of the New England Journal of Medicine.
James Bussel, M.D., of Weill Medical College of Cornell University in New York City and colleagues conducted a phase 1-2 study to determine the safety and efficacy of AMG 531 during and after treatment of immune thrombocytopenia patients with continued low platelet counts after primary therapy. While most treatments for immune thrombocytopenia are aimed at reducing platelet destruction, AMG 531 is designed to boost megakaryocyte production of platelets.
No major adverse effects were seen during the treatment of 41 patients that could be definitely attributed to AMG 531. Four patients had transient post-treatment worsening of thrombocytopenia. Platelet counts returned to baseline after treatment was discontinued. Ten of 16 patients receiving low doses of AMG 531 in the phase 2 study (1 or 3 micrograms per kilogram of body weight per week for six weeks) achieved the targeted range of platelet counts.
"Thrombopoietic agents represent a promising new therapeutic strategy for immune thrombocytopenia that is refractory to second- and third-line therapies," wrote Michael Bromberg, M.D., Ph.D., in an accompanying editorial. "These agents might also serve as an alternative for patients who cannot tolerate immunosuppressive therapy or who are not candidates for it."
The study was funded by Amgen, the manufacturer of AMG 531.
Infant Lung Function May Predict Childhood Asthma
Although reduced lung function is associated with later risk, screening tests not seen as warranted
Newborns with reduced lung function may have an increased risk of developing asthma by age 10, according to a study published in the Oct. 19 issue of the New England Journal of Medicine.
Geir Haland, M.D., of Ulleval University Hospital in Oslo, Norway, and colleagues conducted lung-function tests in 802 Norwegian infants shortly after birth and reassessed 616 (77 percent) of them at age 10.
The researchers found that children whose fraction of peak tidal expiratory flow to total expiratory time was at or below the median at birth were more likely at age 10 to have a history of asthma (24.3 percent versus 16.2 percent) and current asthma (14.6 percent versus 7.5 percent) compared to children whose fraction of peak tidal expiratory flow to total expiratory time was above the median at birth.
"It is important to note that the clinical implications of reduced lung function shortly after birth on an individual level are unclear," the authors write. "Variations of lung function between persons as well as within an individual person a few days after birth are well recognized, and our results indicate that these lung-function measures have low positive predictive value for later asthma. Thus, our data would not support the use of such measures as screening tests for the risk of subsequent asthma."
Endarterectomy Safer Than Stenting for Carotid Stenosis
Study discontinued because of poorer short-term outcome after stenting
In patients with 60 percent or greater carotid artery stenosis, endarterectomy has better survival and a lower incidence of stroke in the short term than stenting, according to the results of a randomized trial published in the Oct. 19 issue of the New England Journal of Medicine. The study was halted early due to the clear superiority of endarterectomy.
In the study, Jean-Louis Mas, M.D., of the Universite Rene Descartes in Paris, France, and the Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial investigators randomized patients to either endarterectomy or stenting. The primary endpoint was stroke or death within 30 days of treatment.
The study was terminated after 527 patients were enrolled because of safety reasons -- the incidence of any stroke or death after endarterectomy was 3.9 percent but 9.6 percent after stenting. Disabling stroke or death was also higher after stenting compared with endarterectomy and the differences were still apparent six months after the procedures.
"Although the EVA-3S trial raises concerns about the safety of carotid stenting and bolsters the call for standardized training and credentialing requirements, it cannot be considered the final word on carotid stenting for patients with an average surgical risk," according to Anthony Furlan, M.D., of the Cleveland Clinic. Stenting should still be considered for symptomatic patients with greater than 70 percent stenosis and with high surgical risk, he points out in an accompanying editorial.
Anti-Aging Hormone Supplements Not Effective
Study shows DHEA, testosterone replacement not the 'fountain of youth'
Neither dehydroepiandrosterone (DHEA) nor low-dose testosterone replacement therapy are effective as anti-aging supplements for elderly women and men, according to a two-year, double-blind, placebo-controlled study published in the Oct. 19 issue of the New England Journal of Medicine.
K. Sreekumaran Nair, M.D., Ph.D., at the Mayo Clinic in Rochester, Minn., and colleagues randomized 87 elderly men with low levels of DHEA and bioavailable testosterone and 57 women with low DHEA to receive one of the two supplements or placebo for two years. Physical performance, body composition, bone mineral density, glucose tolerance, and quality of life measures were used to gauge outcome.
Supplementation with each substance increased their respective plasma levels but had no effects on physical performance, insulin sensitivity, or overall quality of life. While DHEA also had no significant effect on body composition in both sexes, testosterone increased fat-free mass in men and both supplements increased bone mineral density in the femoral neck. No adverse side effects were noted.
"The search for eternal youth will continue, but the reversal of age-related decreases in the secretion of DHEA and testosterone through 'physiologic' replacement regimens offers no answer and should not be attempted," according to Paul Stewart, M.D., of the University of Birmingham, U.K., in an editorial. "Appropriate regulation would dispel much of the quackery associated with [DHEA]."
Rituximab Helps with Refractory Pemphigus Vulgaris
Rituximab plus intravenous immune globulin leads to dramatic, lasting remission
Intravenous immune globulin combined with 10 infusions of rituximab during a five-month period can quickly and safely induce remission among patients with refractory pemphigus vulgaris, according to a study published in the Oct. 26 issue of the New England Journal of Medicine.
A. Razzaque Ahmed, M.D., of the New England Baptist Hospital in Boston, and colleagues treated 11 patients with limited or incomplete response to conventional treatment (high-dose corticosteroids, immunosuppressive agents and intravenous immune globulin) with rituximab plus intravenous immune globulin.
Nine patients showed rapid resolution of lesions and a clinical remission lasting 22 to 37 months. Two patients experienced disease recurrence and were successfully treated with rituximab monotherapy. Remission status correlated with reduction in titers of pathogenic IgG4 antikeratinocyte antibodies and a transient elimination of B-cells. While the long-term consequences of rituximab in patients with autoimmune disease are unknown, it appeared safe in this study.
"We believe that the dramatic and rapid clinical responses we observed can be attributed to rituximab and possibly to synergistic effects of intravenous immune globulin," the authors conclude.
Post-Anticoagulant D-dimer Sign of Recurrent Clot Risk
Fifteen percent of those with abnormal D-dimer levels who halt anticoagulants have events
Thromboembolism patients who have abnormal D-dimer levels a month after stopping anticoagulants are at greater risk of recurrence than other patients, but resuming treatment can reduce the risk, researchers report in the Oct. 26 issue of the New England Journal of Medicine.
Gualtiero Palareti, M.D., of the S. Orsola-Malpighi University Hospital in Bologna, Italy, and colleagues analyzed D-dimer levels one month after anticoagulation therapy was halted in 608 pulmonary embolism or deep-vein thrombosis patients after three months of receiving a vitamin K antagonist. Anticoagulants were then randomly continued or halted in those with abnormal D-dimer levels.
The researchers found that 36.7 percent (223) of the patients had abnormal D-dimer values. Fifteen percent of 120 patients who halted anticoagulants had events, compared with 2.9 percent of the 103 who continued anticoagulant therapy. The researchers report that 24 of the 385 patients (6.2 percent) with normal D-dimer levels, who had not resumed therapy, had a recurrence.
Patients off anticoagulants with abnormal D-dimer levels ran 2.27 times the recurrence risk as those with normal D-dimer levels.
"Patients with an abnormal D-dimer level one month after the discontinuation of anticoagulation have a significant incidence of recurrent venous thromboembolism, which is reduced by the resumption of anticoagulation," the authors write.
Some of the study authors have received lecture fees from Instrumentation Laboratory in Milan.
Spiral CT Scans Can Detect Lung Cancer While Still Curable
Annual spiral computed tomography screening of at-risk patients can boost survival
Yearly spiral computed tomography (CT) screening exams of at-risk individuals can detect lung cancer at a point when it may still be curable, according to a report in the Oct. 26 issue of the New England Journal of Medicine.
Claudia I. Henschke, M.D., Ph.D., of New York Presbyterian Hospital-Weill Medical College of Cornell University in New York City, and colleagues from the International Early Lung Cancer Action Program, screened 31,567 asymptomatic individuals at risk for lung cancer using spiral CT from 1993 to 2005. They re-screened 27,456 participants seven to 18 months after initial screening.
Spiral CT picked up 484 cases of lung cancer, of which 85 percent were clinical stage I with an estimated 10-year lung cancer specific survival rate of 88 percent. Moreover, the survival rate was 92 percent among 302 stage I patients who underwent resection within a month of diagnosis, while eight stage I cancer patients who did not receive treatment died within five years following their diagnosis. Researchers point out that the cost effectiveness of spiral CT for lung cancer rivals that of mammograms for breast cancer.
The new findings are "a provocative, welcome salvo in the long struggle to reduce the tremendous burden of lung cancer on society," writes Michael Unger, M.D., of the Fox Chase Cancer Center in Philadelphia, in an accompanying editorial.
Antibiotic Use for Otitis Media Should Be Limited
Curbing antibiotics for more than half of otitis media cases could reduce antibiotic-resistance risks
Antibiotics for otitis media seem the most beneficial for patients under age 2 who have bilateral infections or children of any age who also have otorrhea, researchers report in the Oct. 21 issue of The Lancet. Other children, which make up more than half of all such patients, could be treated with watchful waiting, a strategy that could cut down on drug-resistant bacteria.
Maroeska M. Rovers, Ph.D., of the University Medical Center in Utrecht, the Netherlands, and colleagues conducted a meta-analysis of six studies, which included 1,643 children aged 6 months to 12 years old. The endpoint was continued pain or fever at three to seven days.
The researchers estimate that four children under age 2 with bilateral infections would need to be treated (number-needed-to-treat) with antibiotics to prevent one case of extended pain and fever. The number-needed-to-treat was 20 for children under age 2 with unilateral infections, nine for children aged 2 or over with bilateral infections, 15 for older children with infection in one ear, and three for children of any age with otorrhea.
In an editorial, Petri S. Mattila, M.D., of Helsinki University Central Hospital in Finland, points out that limiting antibiotics in pediatric otitis would cut medical costs and resistance risks, but "watchful waiting with pain relief must include the exclusion of other bacterial infections, with proper parental education and easy access to follow-up care."
Induced Labor Doubles Risk of Amniotic-Fluid Embolism
Absolute risk of rare complication is low
Women who have their labor induced are twice as likely to develop an amniotic-fluid embolism as their counterparts who don't have a medically induced labor, according to the results of a study published in the Oct. 21 issue of The Lancet.
Michael S. Kramer, M.D., of McGill University in Montreal, Canada, and colleagues studied 180 amniotic-fluid embolisms (24 of which were fatal) that occurred among 2,984,977 single births. The total rate was six amniotic-fluid embolisms per 100,000 deliveries with a fatality rate of 0.8 per 100,000 deliveries.
Women who had their labor induced were twice as likely to experience an amniotic-fluid embolism and fatal cases were 3.5 times more frequent among this group. While the absolute risk for this complication remains low, induction rates have been increasing, the researchers note.
Other risk factors for amniotic-fluid embolism include advanced maternal age, uterine rupture or laceration, placenta previa or abruption, C-section or instrumental vaginal delivery, polyhydramnios and eclampsia, the study showed.
"The researchers have identified definitively the association of medical induction of labor with amniotic-fluid embolism, and delineated the small but important effect this association can have on future obstetric patients ," Jason Moore, M.D., of the University of Pittsburgh, writes in an accompanying editorial.
Sexually Transmitted Disease Re-Infection Risk Is High
Re-screening after three months recommended
Patients with sexually transmitted infections are at high risk of being re-infected after treatment and should be re-screened after three months, according to study findings published Oct. 17 in the Annals of Internal Medicine.
Thomas A. Peterman, M.D., of the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues analyzed data on 2,419 people, of whom 1,236 were women, who were treated for Chlamydia trachomatis, Neisseria gonorrhoeae or, in the case of women only, Trichomonas vaginalis.
Of the women in the cohort, 25.8 percent had one or more new infections, including 11.9 percent with C. trachomatis, 6.3 percent with N. gonorrhoeae and 12.8 percent with T. vaginalis. Among the 1,183 men, 14.7 percent were re-infected, including 9.4 percent with C. trachomatis and 7.1 percent with N. gonorrhoeae. Sixty-six percent of all infections were asymptomatic. Although the re-infection risk declined over time, it remained high for the first year after initial diagnosis.
"Although single-dose therapy may adequately treat the infection, it often does not adequately treat the patient," the authors conclude. "The persistent high risk for new sexually transmitted infections during follow-up suggests that continuing care for persons with diagnoses of infections would benefit the patient and the community."
Rifaximin Can Treat Symptoms of Irritable Bowel Syndrome
In irritable bowel syndrome patients, antibiotic reduces bloating
The symptoms of irritable bowel syndrome can be alleviated by treatment with the gut-selective antibiotic rifaximin, according to the results of a study published in the Oct. 17 issue of the Annals of Internal Medicine.
Mark Pimentel, M.D., of Cedars-Sinai Medical Center in Los Angeles, and colleagues conducted a double-blind, randomized, placebo-controlled study of 87 patients with irritable bowel syndrome who received either 400 mg of rifaximin three times a day for 10 days, or a placebo.
The results of the treatment were measured using a questionnaire administered before treatment and seven days after treatment, and a weekly symptom diary that the patients kept for 10 weeks. Overall, there was an improvement in symptoms for those in the treatment group, and patients experienced less bloating than before treatment. The improvements were sustained over 10 weeks.
The authors concede that the study had only a small sample size and short duration, and call for further studies on a larger scale. "This new concept of irritable bowel syndrome treatment will warrant future studies that allow for head-to-head comparison of antibiotics to other treatment strategies for irritable bowel syndrome, such as prokinetics and probiotics," they write.
The study was supported by a grant from Salix Pharmaceuticals.
Loss of Medicaid Negatively Impacts Health Care
Patients less likely to receive primary care, more likely to have unmet medical needs and medical debt
Adults who lost or had disruptions in Medicaid coverage in Oregon after cost-saving changes were implemented were less likely to receive primary care and more likely to have unmet medical needs and medical debt, researchers report in the September/October issue of the Annals of Family Medicine.
Matthew J. Carlson, Ph.D., from Portland State University in Oregon, and colleagues surveyed 2,783 adults who had been enrolled in the Oregon Health Plan for at least 30 days before nationwide cost-saving changes in Medicaid programs were implemented. Thirty-one percent of adults reported losing their health insurance and 15 percent reported disruptions in coverage.
In the 10 months after changes in the health plan took place, those who lost coverage or had disruptions in coverage were less likely to receive primary care (odds ratio 0.18 and 0.66, respectively), more likely to have unmet health care needs (OR, 5.55 and 1.85, respectively), and more likely to report medical debt (OR, 3.06 and 1.99, respectively). Those who lost coverage were also more likely to have unmet medication needs (OR, 2.05), the report indicates.
"Medicaid program changes that increase cost sharing and limit enrollment have significant negative impacts on health care access and utilization among Medicaid beneficiaries; these impacts occur rapidly, within the first 10 months after changes," the authors conclude.
Chronic Diseases Increase Psychological Distress
Likelihood of psychological distress associated with disease severity
Patients with multiple chronic diseases such as arthritis or diabetes are more likely to experience psychological distress with increasing disease severity, according to the results of a study published in the September/October issue of the Annals of Family Medicine.
Martin Fortin, M.D., from Sherbrooke University in Quebec, Canada, and colleagues examined the relationship between psychological distress and multi-morbidity (having more than one chronic disease) in 238 patients with chronic diseases. Psychological distress was assessed through a psychiatric symptom questionnaire.
The researchers found that multi-morbidity was significantly related to psychological distress when using a scale that accounted for disease severity (odds ratio 1.67). The risk of psychological distress increased with disease severity, with an odds ratio of 4.67 for patients with the most severe disease, according to the study.
"Psychological distress increased with multi-morbidity when we accounted for disease severity," Fortin and colleagues conclude. "Clinicians should be aware of the possible presence of psychological distress, which can further complicate the comprehensive management of these complex patients."
Low Elder Abuse Reporting Related to Physician Concerns
Many physicians worry about their ability to do what is best for their patients
Concern over the patient-physician relationship and patient quality of life may each play a role in why physicians have a low rate of reporting suspected elder abuse, researchers report in the September/October issue of the Annals of Family Medicine.
Michael A. Rodriguez, M.D., M.P.H., and colleagues from the University of California Los Angeles, interviewed 20 primary care physicians regarding factors influencing their likelihood of reporting elder abuse.
The researchers found that the physicians were concerned about how reporting suspected abuse would affect the physician-patient relationship (50 percent of physicians), the patient's quality of life (60 percent of physicians), and the physician's control in terms of their ability to do what is best for the patient or protecting themselves from legal liability (55 percent of physicians).
"Primary care physicians appear to be subject to paradoxes of reporting that contribute to the underreporting of elder abuse," Rodriguez and colleagues conclude. "These paradoxes and alternative modes of managing paradoxes are important and should be addressed in educational and training programs for physicians, and systematic evaluation of these issues may help to inform future legislation in this area."
Serious Complications for Undiagnosed Diabetes Cases
Authors don't advocate mass screening, but suggest current strategy may be too late for some
Nearly one-third of diabetes cases in the United States remain undiagnosed, and many of these already have diabetes-associated complications, including nephropathy, according to a report in the September/October issue of the Annals of Family Medicine.
Using data from the 1999-2002 United States National Health and Nutrition Examination Survey, Richelle Koopman, M.D., and colleagues from the Medical University of South Carolina in Charleston, measured the prevalence of positive screening tests for nephropathy and peripheral neuropathy in adults 40 years or older with undiagnosed diabetes.
Their review identified nephropathy in 26.5 percent of those with undiagnosed diabetes compared with 7.1 percent of those without the disease, producing a nephropathy odds ratio of 2.35 for undiagnosed diabetes. Peripheral neuropathy occurred in 21.5 percent of the undiagnosed group compared with 10.1 percent of those without disease, but was not significant after adjustments for age.
"Although the results presented here do not lead us to advocate mass screening, they do sensitize us to the point that the current approach of detecting diabetes once clinical signs and symptoms are apparent may be too late to prevent complications and may be a strategy in need of review," the authors write.
Men with Regular Care More Apt to Discuss PSA Test
Review of 2000 NHIS data shows 63 percent of tested men discuss pros and cons of test
Older men with a usual source of health care and blacks are more likely to discuss the advantages and disadvantages of the prostate-specific antigen test with their doctor, according to a report in the September/October issue of the Annals of Family Medicine.
Stephanie L. McFall, Ph.D., from the University of Texas Health Science Center in San Antonio, reviewed data from 2,184 men aged 50 or older who were enrolled in the 2000 National Health Interview Survey and reported a screening prostate-specific antigen (PSA) test.
Overall, 63 percent of tested men reported having a discussion about the advantages and disadvantages of a PSA test prior to the exam. Sixty-four percent of those with a regular source of health care reported having a discussion, compared to only 38 percent without a usual source of care. Blacks were more likely to have a discussion than other races, perhaps because physicians are aware of their greater risk for prostate cancer.
"Because men with no regular source of care may be screened in special events, e.g., health fairs, plans for such events should build in opportunities to learn about the benefits and risks of the PSA test," McFall concludes.
Moderate Drinking Decreases Men's Heart Attack Risk
Study shows that moderate drinking could complement other healthy lifestyle interventions
Moderate drinking may lower the risk of heart attack in healthy men, researchers report in the Oct. 23 issue of the Archives of Internal Medicine.
Kenneth J. Mukamal, M.D., of the Beth Israel Deaconess Medical Center in Boston, and colleagues analyzed data from the Health Professionals Follow-up Study on 8,867 men aged 40 to 75. All the subjects were non-smokers who ate healthy diets, exercised at least 30 minutes per day and had a body mass index (BMI) of less than 25.
Between 1986 and 2002, the researchers found that 106 men had heart attacks. Compared with abstention, they calculated that the hazard ratios for heart attack were 0.98 for alcohol intake of 0.1-4.9 grams per day, 0.59 for alcohol intake of 5.0-14.9 g/d, 0.38 for alcohol intake of 15-29.9 g/d, and 0.86 for alcohol intake of 30 g/d or more. After comparing men who drank 5.0 g/d or more with those who drank less than 5.0 g/d, they estimated that 25 percent of the incidence cases of heart attack in the low-consumption group were attributable to consuming less than 5.0 g/d.
"Our results suggest that moderate drinking could be viewed as a complement, rather than an alternative, to these other lifestyle interventions [physical activity, weight reduction and smoking abstinence], a viewpoint espoused by some authors," Mukamal and colleagues conclude.
Testosterone Levels Affect Men's Risk of Falling
Older men with the lowest levels have 40 percent higher risk than those with the highest levels
Older men with low testosterone levels have an increased risk of falling, according to study findings reported in the Oct. 23 issue of the Archives of Internal Medicine.
Between March 2000 and April 2002, Eric Orwoll, M.D., of the Oregon Health & Science University in Portland, and colleagues assessed testosterone levels in 2,587 men aged 65 to 99 (average age 73) and followed them through March 2005.
The researchers found that men with testosterone levels in the lowest quartile had a 40 percent higher risk of falling than those in the highest quartile. They also found that low testosterone levels in younger men (aged 65 to 69) were strongly associated with falls (relative risk, 1.8), while testosterone levels were not associated with falls in the oldest men (aged 80 and older).
"These findings strengthen the link between testosterone and the health of older men, suggesting that the effects of testosterone on fall risk may be via novel mechanisms and provide insight into how testosterone measurements might be useful for identifying men at higher risk for adverse events," the authors conclude. "Moreover, these results provide additional justification for trials of testosterone supplementation in older men and should aid in the design of those studies."
Anxiety Disorders Associated with Physical Conditions
Need seen for improved recognition and treatment of anxiety disorders in clinical practice
Anxiety disorders are linked with many serious physical conditions, a co-morbidity that increases the risk of disability and a poor quality of life, according to the results of a study published in the Oct. 23 issue of the Archives of Internal Medicine.
Jitender Sareen, M.D., of the University of Manitoba in Winnipeg, Canada, and colleagues studied 4,181 German adults, including 429 (8.4 percent) who had had an anxiety disorder within the previous month and 2,610 (60.8 percent) who had had a physical condition within the previous month.
The researchers found that anxiety disorders were independently associated with thyroid disease, respiratory disease, gastrointestinal disease, arthritis, migraine headaches and allergic conditions (adjusted odds ratios between 1.39 and 2.12). Compared with physical disorders alone, the presence of an anxiety disorder with one or more physical disorders was associated with poorer physical component scores on the Medical Outcomes Study 36-Item Short-Form Health Survey and past 30-day disability due to physical problems (adjusted odds ratio, 1.69).
"In combination with recent data demonstrating that anxiety disorders are risk factors for suicidal behavior, the current study suggests that anxiety disorders should be considered an important public health problem in the community," the authors conclude. "During the last decade, efforts have been substantially increased to improve recognition and treatment of depression in general practice. Similar efforts should be strongly considered for anxiety disorders."
Polycystic Ovary Syndrome More Common in the Obese
Disease prevalence five times higher in overweight and obese than in leaner women
Overweight and obese women have five times the incidence of polycystic ovary syndrome than do leaner women, according to the results of a Spanish study published in the Oct. 23 issue of the Archives of Internal Medicine.
Francisco Alvarez-Blasco, M.D., of the Hospital Universitario Ramon y Cajal in Madrid, and colleagues evaluated 113 overweight or obese premenopausal women for polycystic ovary syndrome from May 2002 to December 2005. In Spain, the rate of polycystic ovary syndrome in lean women is 5.5 percent.
Thirty-two women (28.3 percent) were diagnosed with polycystic ovary syndrome, with the degree of obesity not contributing to the prevalence. Additionally, three women had hyperandrogenemia, two presented with idiopathic hirsutism, two had chronic oligomenorrhea and two had oligomenorrhea with hyperprolactinemia. The other 72 women (63.7 percent) had no hyperandrogenic symptoms or reproductive abnormalities.
"We conclude that physicians treating overweight and obese patients should be aware of the high prevalence of polycystic ovary syndrome among these women and that screening for polycystic ovary syndrome, at least by obtaining a detailed menstrual history and a careful clinical evaluation of hyperandrogenic symptoms, should be conducted routinely to diagnose polycystic ovary syndrome and ameliorate the health burden distinctly associated with this prevalent disorder," the authors write.
Thromboprophylaxis Effective in Post-Acute Care of Elderly
Adherence to evidence-based guideline significantly decreased deep venous thrombosis
An evidence-based, multifaceted venous thromboprophylaxis intervention designed to increase clinicians' compliance with clinical guidelines significantly decreased the incidence of deep venous thrombosis in elderly post-acute care patients, according to a paper in the Oct. 23 issue of the Archives of Internal Medicine.
Elodie Sellier, M.D., of Joseph Fourier University in Grenoble, France, and colleagues evaluated 1,373 patients aged 65 and older for deep venous thrombosis before (709 patients) and after (664 patients) implementation of a multifaceted evidence-based thromboprophylaxis intervention guideline.
Deep venous thromboses were found in 91 pre-intervention patients (12.8 percent) and in 52 post-intervention patients (7.8 percent). Pharmacologic prophylaxis -- including high-risk dose low-molecular-weight heparin, unfractionated heparin, or vitamin K -- was similar in both groups. However, post-intervention patients used graduated compression stockings more often (27.4 percent versus 34.6 percent) and were less likely to be given low-risk dose heparin.
"A multifaceted intervention addressing venous thromboembolism prophylaxis in post-acute care patients can be followed by a significant decrease in the rate of any deep venous thrombosis in elderly patients. More active interventions are needed to enforce compliance with evidence-based guidelines," the authors conclude.
Some of the study authors consult for Sanofi-Aventis France.
Self-Management of Arthritis Does Not Reduce Pain
It lowers anxiety but not physical functioning or contact with physicians
Self-management programs for arthritis patients improve their perceived handling of their condition but have no impact on pain, physical functioning or the amount of time they spend visiting the doctor, according to study findings published online Oct. 13 in BMJ.
Marta Buszewicz, of the Royal Free and University College Medical School of London, U.K., and colleagues conducted a study of 812 patients aged 50 and above with osteoarthritis of the hips and/or knees, and pain, disability or both. All participants received an education booklet but half were also randomized to receive six sessions on how to self-manage arthritis. The subjects were assessed at baseline, four months and 12 months.
Those in the intervention group scored significantly higher than the control group on scales of anxiety, self-efficacy for pain management and self-efficacy for other aspects of management. However, in both groups, intention to treat and contact with primary care physicians was the same.
"Little doubt exists that such techniques provide some benefit for those with chronic conditions, but the best way to provide the intervention is unclear, and insufficient evidence exists to justify a policy of active recruitment of patients from primary care settings," the authors conclude.
Depression in Heart Failure Linked to Poorer Outcomes
Meta-analysis finds much higher depression rates in those with advanced disease
Although one in five heart failure patients reports clinically significant depression -- which is linked to poorer outcomes -- the rate may be higher in those who have advanced disease or when patients are screened with questionnaires, according to research in the Oct. 17 issue of the Journal of the American College of Cardiology.
Thomas Rutledge, Ph.D., of the VA San Diego Health Care System in California, and colleagues performed a meta-analysis of 36 studies that examined heart failure and depression including prevalence, outcomes and treatment efficacy.
Clinically significant depression was reported in 21.5 percent of patients, depending on whether questionnaires or diagnostic interviews were used (33.6 percent and 19.3 percent, respectively) and increased with disease severity. Depressed patients had higher death and secondary event rates, and there was a trend toward more hospitalization. Treatment studies suggested a reduction in depression symptoms, the researchers found.
"Clinically significant depression is present in at least one in five patients with heart failure; however, depression rates can be much higher among patients screened with questionnaires or with more advanced heart failure. The relationship between depression and poorer heart failure outcomes is consistent and strong across multiple end points. These findings reinforce the importance of psychosocial research in heart failure populations and identify a number of areas for future study," the authors concluded.
Peripheral Arterial Disease Linked to Higher Mortality
Condition independently predicts death after percutaneous coronary procedures
Concomitant peripheral arterial disease is linked with higher mortality after percutaneous coronary intervention and myocardial infarction, and independently predicts short- and long-term death rates, according to research in the Oct. 17 issue of the Journal of the American College of Cardiology.
Jacqueline Saw, M.D., of the University of British Columbia in Vancouver, Canada, and colleagues performed a pooled analysis of 19,867 patients who had percutaneous coronary intervention, 1,602 of whom had peripheral arterial disease. The researchers used multivariable analysis to examine seven- and 30-day outcomes and six-month and one- year events.
Peripheral arterial disease was linked to higher mortality or myocardial infarction at all time points, and showed a trend towards an increased risk of major bleeding. The authors found peripheral arterial disease significantly predicted mortality at 30 days (hazard ratio, 1.67), six months (hazard ratio, 1.76) and one year (hazard ratio, 1.46).
"The presence of peripheral arterial disease is associated with higher rates of post-percutaneous coronary intervention death and myocardial infarction, and is anindependent predictor of short- and long-term mortality," the authors conclude.
Prepared jointly by the editors of Medical Economics and HealthDay's Physicians Briefing (www.physiciansbriefing.com).